Clearinghouse System for the Collection, Management and Identification of 340B Related Pharmaceutical Claims Under Various Medicaid and Medicaid Managed Care Programs

Abstract

The present invention is directed to an exchange clearinghouse, to provide an improved method of processing all 340B Drug Pricing Program claims for all involved parties, to easily identify and report the 340B claims as well as overcome any challenges of the prior art without compromising security or accuracy. More particularly, the invention is a method that can alter, change, or reclassify previously adjudicated pharmacy claims (original claims) through a system, outside of and unrelated to the system used by the pharmacy service provider who adjudicated the original claim. This creates a reversing claim of the original claim and recreates an altered, changed or reclassified original claim. The Method also allows for the collection and reporting of accurate quantities of the original claim in which 340B priced drugs were used.

Description

PRIORITY CLAIM TO RELATED APPLICATION[0001]This application claims the benefit of previously-filed U.S. Provisional Patent Application, Ser. No. 61 / 994,456, filed on May 16, 2014, entitled “Clearinghouse System for Processing Pharmaceutical Funding Claims Under Various Medicaid Programs”, as well as previously-filed U.S. Provisional Patent Application, Ser. No. 62 / 018,206, filed on Jun. 27, 2014, entitled “Clearinghouse System for Processing Pharmaceutical Funding Claims Under Various Medicaid Programs.” The entireties of those previously-filed applications are incorporated herein by this reference.BACKGROUND[0002]1. Field of the Invention[0003]The present invention relates generally to computerized systems for consolidated processing of Medicaid claims and, more particularly, to consolidated 340B Medicaid processing systems that are accessible to various user types through internet portals, by which data is collected, validated and managed as part of a pharmaceutical rebate program...

AI Technical Summary

Benefits of technology

[0018]The present invention is directed to an exchange clearinghouse, to provide an improved method of processing all 340B Drug Pricing Program claims for all involved parties, to easily identify and report the 340B claims as well as overcome any challenges of the prior art without compromising security or accuracy.

[0019]The primary purpose of the present invention is to improve upon the prior art and enable better management of all aspects of processing and fulfilling 340B funded pharmaceutical supply chains. More particularly, the invention is a method that can alter, change, or reclassify previously adjudicated pharmacy claims (original claims) through a system, outside of and unrelated to the system used by the pharmacy service provider who adjudicated the original claim. This creates a reversing claim of the original claim and recreates an altered, changed or reclassified original claim. The Method also allows for the collection and reporting of accurate quantities of the original claim in which 340B priced drugs were used.

[0021]In general, many embodiments of the invention provide a computer program product that utilizes a safe and secure environment for allowing providers, pharmacies, and 340B administrators to submit data files for identification directly relating to 340B claims. The present invention uses computers to complete the matching, altering, and modification of pharmacy claims at a speed and efficiency that cannot be achieved by hand based methods.

[0024]While the benefits of the invention are more numerous than mentioned here, the use of such clearinghouse system creates a seamless solution for managed care providers to identify and report 340B claims. The resulting system allows for a singular streamlined system and other cost efficiencies while maintaining the rigid privacy and security requirements of HIPAA.

Problems solved by technology

The United States Congress has tried time and again to help ensure affordable healthcare in the face of ever-increasing pharmaceutical costs, but the implications for healthcare providers are often confounding.

Nice idea, but it unexpectedly caused overall prices to drastically increase.

Because the required rebate was based on each manufacturer's “best price”, the program nullified any incentive for manufacturers to reduce their prices in non-Medicaid markets, as doing so would lead to larger rebates in the Medicaid market.

Despite the long history and wide spread industry use of the 340B Drug Pricing Program, the program still presents significant challenges for all parties involved.

For example, while numerous medical providers rely on the program, it is difficult for those providers to effectively submit, process and manage claims under the 340B program.

A similar problem with the current system is that a significant amount of time, labor and effort is required for every pharmaceutical drug manufacturers or wholesalers to verify that each entity requesting the special 340B discounted rebate price has in fact been registered, approved, and enrolled in the 340B Drug Pricing Program.

Another problem with the current system is that each health center can have its own negotiated price with a manufacturer for a certain pharmaceutical drug.

Health Centers can, negotiate prices with the manufacturers that are below the 340B Program drug price, thereby creating additional difficulty in processing the 340B Rebates as there is no singular price.

However, since health centers must charge patients differently for the drugs, dependent on whether each individual patient qualifies to receive the drug at the discounted 340B price, thereby created an issue in verifying that drug manufacturers are repaid.

A similar problem with the current system is that health centers must keep track of which program is paying for the drugs in order to maintain compliance with the 340B rules.

As a result, there are numerous shortcomings, to both the patient and the provider, of the current system as utilized in the industry, which causes devastating financial implications, and therefore, as a consequence patient care could be compromised.

Many other problems, obstacles, limitations and challenges will be evident to those skilled in the art, particularly in light of the literature and experiences that are known in the industry.

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